Basic Information
| Provider Information | |||||||||
| NPI: | 1821228743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARDNER TAYLOR | ||||||||
| OtherFirstName: | CHARLENE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 356 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672010356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
| FaxNumber: | 8003747656 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
| FaxNumber: | 8003747656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1382074072 | KS | N | Nursing Service Providers | Registered Nurse | 367500000X | 140196 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 556929 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200634060A | 05 | KS | MEDICAID |